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'<BOVM STATE OF CALIFORNIA G (. STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL F]ONE ITEM ❑ 2 INTERIM PERMIT ` ] 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAORFA LITYNAME� Q � NAMEOFOPERATOR ADDRES inni NEAREST CROSS STREET PARCEL%(OPTIONAL) 2O 0S S. -CITY NAME STATEZIP CODE SITE � PHONE%WITH AR E 9A9 CA 3 ^a TO INDI ATE CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Q COUNTY AGENCY E-1 STATE AGENCY O FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ,/ IF INDIAN %OF TANKS AT SITE E.P.A. I.D.%(aptlorral) RESERVATION 3 FARM O 4 PROCESSOR Q S OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COr If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindicate INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY l�CORPORATION D PARTNERSHIP COUNIYAGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box b ineicale = INDIVIDUAL E�j LOCAL AGENCY STATE-AGENCY L�j CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERALAGENCY CITY NAME STATE 7CODE PHONE%WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ F4-J-4]-[T7FM V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ xx b inelcaie O I SELF INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND O 5 LETTER OF CREDIT a 6 EXEMPTION O 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ H.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# O LOCATION CODE -OPTIONAL CENSUS TRACT% -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 3 z THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(5.91) FORD 33A.5 A/